Hindawi

Journal of Pregnancy
Volume 2020, Article ID 4871494, 8 pages
https://doi.org/10.1155/2020/4871494

Research Article
Lifetime Prevalence of Abortion and Risk Factors in Women:
Evidence from a Cohort Study

Mehdi Moradinazar , Farid Najafi, Zeinab Moradi Nazar, Behrooz Hamzeh, Yahya Pasdar,
and Ebrahim Shakiba
Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences,
Kermanshah, Iran

Correspondence should be addressed to Ebrahim Shakiba; [email protected]

Received 2 October 2019; Revised 2 February 2020; Accepted 21 February 2020; Published 27 April 2020

Academic Editor: Olav Lapaire

Copyright © 2020 Mehdi Moradinazar et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. 10-20% of pregnancies end due to spontaneous abortions. In recent years, nondocumentary evidence has been
indicative of an increase in the prevalence of nonspontaneous abortions in Iran, especially in the Kurdish regions. The aim of
this study is to assess the lifetime prevalence of spontaneous abortions and factors affecting spontaneous abortion in women
35-65 years old. Method. Data from the recruitment phase of Ravansar Non-Communicable Disease (RaNCD) cohort study
was used. All of the 4831 married women 35-65 years old and with history of pregnancy were included in this study. In order
to determine the abortion ratio, the number of abortions was divided by the number of live births, and multiple logistic
regression analysis was applied to determine associated factors affecting abortion. Results. About 25.7% of women had a history
of spontaneous abortion. The abortion ratio in women was 0.10. The abortion ratio in women with secondary education, first
pregnancy and marriage age at ≥26, socioeconomic condition, and hyperthyroid and diabetes was high while the abortion ratio
of women with high physical activity and BMI < 18:9 or residents of rural area was low. After assessing the effective variables,
it was found that women with high blood pressure have 63% less odds for nonspontaneous abortion, which is statistically
significant (p value < 0:05). Conclusion. Considering the effect of factors such as level of education, older age at the first
marriage, and age at the first pregnancy on increased chance of spontaneous abortion, measures should be taken to take more
care for these people.

1. Introduction challenging because most abortions have not been reported

to and recorded in their official health system [8].
Spontaneous abortion is one of the most common complica- In more than half of the cases, the causes of abortion have
tions of pregnancy [1]. In general, expulsion of an embryo or been genetic disorders and chromosomal abnormalities [9,
fetus before it reaches a stable stage of life is called abortion 10]. Nevertheless, other factors affecting abortion are as fol-
[2]. Studies indicate that the incidence of spontaneous abor- lows: uterine abnormalities [11, 12], infectious diseases and
tion is between 10 and 20% [3–5]. It should also be noted that untreated diseases of the mother [1, 4], the age of the mother
most of the spontaneous abortions occur in the early weeks of during pregnancy, previous history of abortion [1, 13, 14],
pregnancy, and therefore, it can be confused with menstrual age at the first menstruation [15], menstrual disorders [1],
bleeding [1, 6, 7]. Generally, it is very difficult to determine use of contraceptive drugs [1, 14], BMI > 25 kg/m2 [16–19],
the rate of spontaneous and unwanted abortions because in environmental conditions and mother’s lifestyle such as
countries where legal abortion is prohibited, there is a possi- smoking [20, 21] and use of caffeine [12, 13], being exposed
bility of false report. Besides, the study of spontaneous abor- to cigarette smoke [22, 23], stress [12, 24], exposure to
tion in low- and middle-income countries is also very mobile phone radiation [25], and low socioeconomic and
 7097, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/4871494 by Nat Prov Indonesia, Wiley Online Library on [24/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 Journal of Pregnancy

employment status [26], which are effective in the occur- fied as low (MET 24-36.5 hours per week), moderate (MET
rence of abortion. 36.6-44.9 hours per week), and heavy (MET ≥45 hours per
Abortion is a distressing experience that affects the week) [32]. To measure the quality of nutrition, Healthy Eat-
mother in a variety of ways by influencing on emotional sta- ing Index (HEI)—based on the guidelines in 2015—was cat-
tus that can finally result in psychological disorders such as egorized into five groups [33]. In this study, any self-reported
depression [27]. Although the prevalence of maternal abor- pregnancy ended spontaneously before week 20 is regarded
tion and miscarriage in Iran is stable, the number of new as abortion. In order to determine the abortion ratio, the
cases is slightly increasing. In fact, Iran is now facing with a number of abortion was divided by the number of live births.
decrease in population growth plus which is partly attributed
to the increase in number of divorce and decrease in number 2.4. Statistical Methods. Continuous variables were men-
of marriage among young men and women. While the nation tioned as mean ± standard deviation, and qualitative vari-
is now trying to stabilize the growth of the population, a clear ables were measured by frequency (%). In order to
feature about the burden of abortion can help to understand investigate about the risk factors of abortion, at first, a uni-
the whole scenario. On the other hand, abortion is closely variate logistic regression analysis was performed. Then, var-
related to the cultural and religious factors, and Iran is a mul- iables with p < 0:3 were entered in the multiple model.
ticultural country with different ethnicities. Kurdish people Thereafter, variables with p < 0:05 were kept, and other vari-
mostly inhabited in western part of Iran with an integrated ables were excluded using a stepwise (Backward) method. In
culture and life style. This study seeks to determine the life- all of the analyses, missing values were deleted (less than 1%).
time prevalence of abortion and its risk factors in women All the analyses were performed using the STATA V.14
35-65 years old who have participated in the first cohort (STATA Corp LLC) software. P values < 0:05 were consid-
study among Kurdish people named Ravansar Non- ered as statistically significant.
Communicable Disease (RaNCD) cohort study.
3. Results
2. Methodology
From of 4831 women participants, 2083 (58%) of them were
2.1. The Study Population. This cross-sectional study was urban residents, and the rest were rural residents. 3472
conducted based on the population recruited for the RaNCD (72.2%) of them experienced their first menstrual bleeding
cohort study—a member of centers participated in Prospec- when they were between 13 and 16 years old. The education
tive Epidemiological Research Studies in Iran (PERSIAN). level of 2202 (45.9%) of the participants was between 1 and 5
The recruitment phase began in November 2014 and ended years, and 3608 (74.8%) women had no consanguineous
in February 2017. During the course of this research, 10065 marriage. In total, 1241 (25.7%) had at least one spontaneous
subjects willingly participated and signed the written abortion during her life.
informed consent letter. Further details have been presented After adjustment for other variables, with the increase in
elsewhere [28, 29]. the number of pregnancies, the risk for spontaneous abortion
also increased; i.e., the odds for abortion in studied women
2.2. Inclusion and Exclusion Criteria. Among all participating who experienced more than 6 pregnancies was 8.3 (6.6-
women, those with history of pregnancy were selected. In the 10.5) times significantly more than those with 1-3 pregnan-
RaNCD cohort study, the inclusion criteria for women were cies. The odds of abortion in women who married after
willingness to participate and complete the research, provid- 26 years old was 1.6 (1.02-2.4) times significantly more
ing the signed written informed consent letter, and being than the other. In addition, the risk of abortion in women
capable of communication with the research team. For the who had their first pregnancy at age greater than 26 years
purpose of this study, we excluded those who had no history old was 1.9 (1.3-2. 8) times significantly more than the
of marriage and pregnancy. others. Education level was an effective factor in spontane-
ous fetus abortion; i.e., with an increase in education level,
2.3. Definition and Measurements. Socioeconomic status the risk of abortion increased (Table 1). The highest abor-
(SES), the main variable indicative of economic status of tion ratio was witnessed in women with secondary educa-
the family, was calculated by principal component analysis tion (Figure 1).
(PCA) and considered the subjects’ wealth and social charac- From the total of women with past history of abortion,
teristics. Accordingly, the studied population was categorized 24.8% had been using contraceptive pills. After adjusting
into 5 quintiles: the poorest, the poor, the middle class, the the variables, it was shown that the use of pills is a protective
rich, and the richest [30]. BIA device (InBody 770 BIO- factor for spontaneous abortion. Therefore, women who had
SPACE, Korea) was used for weight measurement. The been taking contraceptives pills had 22% less risk of abortion
heights measured with 0.1 accuracy using stadiometer [31]. compared to those who had been using other contraceptive
A 19-item inventory related to light, moderate, and severe method which was statistically significant. Secondhand
physical activities was used to collect information about the smoking nonsignificantly increased the odds ratio of abor-
subjects’ physical activity, and then, the Metabolic Equivalent tion = 1.1 (95% C.I: 1.0-1.3). People who had the highest
of Task (MET) rate of each activity was obtained based on SES were in the greater risk of abortion (Table 1).
Compendium of Physical Activities to calculate daily MET Compared to others, women with secondary education
rates of each participant. Physical activity levels were classi- and those with marriage and first pregnancy age greater
 7097, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/4871494 by Nat Prov Indonesia, Wiley Online Library on [24/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Pregnancy 3

Table 1: Descriptive statistics of the sampled population and the results of the logistic regression model for risk factors of spontaneous
abortion.

Total Abortion Abortion ratio Adjusted

Variables
N (%) N (prevalence) Mean (SD) OR (95% CI)
Total (%) 4831 (100) 1241 (25.7) 0.10 (0.2)
Menstruation start age
<12 years 1031 (21.4) 276 (26.8) 0.11 (0.2) 1
13-16 years 3472 (72.2) 891 (25.7) 0.11 (0.2) 0.9 (0.8-1.1)
>17 years 306 (6.4) 64 (20.9) 0.07 (0.1) 0.7 (0.5-1.0)
Pregnancy number
1-3 1799 (37.3) 255 (14.2) 0.09 (0.2) 1
4-5 1376 (28.5) 420 (30.5) 0.14 (0.3) 4.5 (3.7-5.5)
≥6 1648 (34.2) 558 (33.8) 0.10 (0.2) 8.3 (6.6-10.5)
First pregnancy age (year)
15 611 (12.7) 169 (27.6) 0.08 (0.2) 1
15-20 2469 (51.2) 620 (25.1) 0.09 (0.2) 0.9 (0.8-1.2)
21-25 1159 (24.1) 286 (24.7) 0.11 (0.2) 1.3 (0.9-1.6)
≥26 581 (12.1) 155 (26.7) 0.20 (0.4) 1.9 (1.3-2. 8)
First marriage age (year)
≥15 1406 (29.1) 375 (26.7) 0.08 (0.2) 1
16-20 2338 (48.4) 593 (25.4) 0.10 (0.2) 1.2 (0.9-1.4)
21-25 728 (15.1) 174 (23.9) 0.12 (0.2) 1.2 (0.9-1.6)
≥26 358 (7.4) 98 (27.4) 0.19 (0.4) 1.6 (1.0-2.4)
Level of education
Illiterate 1791 (37.3) 433 (24.1) 0.06 (0.1) 1
1-5 years 2202 (45.9) 582 (26.4) 0.12 (0.3) 1.8 (1.5-2.1)
6-9 years 461 (9.6) 123 (26.8) 0.14 (0.3) 2.4 (1.8-3.2)
10-12 years 243 (5.1) 62 (25.5) 0.18 (0.4) 2.4 (1.6-3.5)
≥13 years 111 (2.1) 41 (36.9) 0.23 (0.3) 3.5 (2.1-5.8)
Place
Urban 2083 (58.0) 772 (34.7) 0.12 (0.3) 1
Rural 1507 (42.0) 469 (31.1) 0.09 (0.2) 0.9 (0.8-1.1)
Consanguineous marriage
No 3608 (74.8) 934 (25.9) 0.10 (0.2) 1
First degree 678 (14.1) 172 (25.4) 0.11 (0.3) 0.9 (0. 8-1.2)
Second degree 541 (11.1) 135 (2.9) 0.09 (0.2) 0.9 (0. 8-1.2)
Smoking status
No 4548 (94.4) 1166 (25.6) 0.11 (0.2) 1
Current 105 (2.2) 22 (20.1) 0.05 (0.1) 0.7 (0.4-1.2)
Former 165 (3.4) 48 (29.1) 0.07 (0.1) 1.2 (0.8-1.7)
Secondhand smoking
No 2446 (50.6) 599 (24.5) 0.10 (0.2) 1
Yes 2385 (49.4) 642 (26.9) 0.11 (0.3) 1.1 (1.0-1.3)
BMI
<18.9 52 (1.1) 7 (14) 0.09 (0.2) 1
19-24.9 965 (20.1) 229 (23.7) 0.11 (0.2) 1.9 (0.8-4.6)
25-29.9 1952 (40.6) 504 (25.8) 0.12 (0.2) 2.2 (0.96-4.9)
30-34.9 1381 (28.8) 380 (27.5) 0.09 (0.2) 2.4 (1.1-5.5)
>35 452 (9.4) 115 (25.4) 0.9 (0.2) 2.3 (0.9-5.3)
 7097, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/4871494 by Nat Prov Indonesia, Wiley Online Library on [24/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Journal of Pregnancy

Table 1: Continued.

Total Abortion Abortion ratio Adjusted

Variables
N (%) N (prevalence) Mean (SD) OR (95% CI)
Physical activity daily METs
24-36.5 1036 (21.4) 261 (25.2) 0.11 (0.3) 1
36.6-44.9 3302 (68.4) 862 (26.1) 0.11 (0.2) 1.1 (0.9-1.3)
≥45 492 (10.2) 118 (23.9) 0.08 (0.2) 1.0 (0. 8-1.4)
Use contraceptive drug
No 812 (16.8) 240 (29.5) 0.13 (0.3) 1
Yes 4013 (83.2) 996 (24.8) 0.10 (0.2) 0.8 (0.6-0.9)
Socioeconomic status
1st quantile (the poorest) 968 (20.1) 236 (24.4) 0.08 (0.2) 1
2nd quantile 966 (20.0) 222 (22.9) 0.09 (0.2) 0.9 (0.7-1.1)
3rd quantile 962 (19.9) 242 (25.1) 0.09 (0.2) 1.0 (0.8-1.3)
4th quantile 968 (20.1) 248 (25.6) 0.11 (0.3) 1.0 (0.8-1.3)
5th quantile (the richest) 962 (19.9) 291 (30.2) 0.15 (0.3) 1.4 (1.1-1.8)
Thyroid
No 4546 (94.1) 1159 (25.5) 0.10 (0.3) 1
Hypo 261 (5.4) 73 (27.9) 0.1 (0.2) 1.1 (0.8-1.5)
Hyper 24 (0.5) 9 (37.5) 0.14 (0.2) 1.8 (0.7-4.5)
Blood pressure
No 4465 (92.7) 1158 (25.9) 0.11 (0.2) 1
Yes 353 (7.33) 76 (21.5) 0.12 (0.3) 0.6 (0.5-0.8)
Goodness of fit model
Sensitivity 19.15%
Specificity 95.25%
Accuracy 75.97%
Positive predictive value 57.79%
Negative predictive value 77.63%

0.25
>13
Mean abortion ratio

0.2 Yes 25-45

25-45
10-12 year
11
0.15 12 6-9 year 0 Hyper Richest
No
City 13 1-5 year 21-25 First degree
16 No 24-36.5 Yes
36.6-44. 30.0–3 21-25 4
14 Hypo No 25.0–2
0.1 Village 15 3 15-20
Second degree No 19-24.9 Yes Yes
32
12
17 1 15-20
No <15 ≥45 No <15 Poorest
19
Illiterate1
0.05 18 Yes <18.9
Place

Menstruation start age

Blood pressure

Education years

Pregnancy number

GDM

yroid

Marriage age

Family marriage

METs

Secondhand smoke

Pregnancy age

OCPs
WHR

SES
BMI

Risk factors of spontaneous abortion

Figure 1: Mean abortion ratio based on the studied variables in the participants of RaNCD.
 7097, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/4871494 by Nat Prov Indonesia, Wiley Online Library on [24/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Journal of Pregnancy 5

than 26 years, higher SES, past history of hyperthyroidism, The odds for spontaneous abortion increased with
and diabetes had a higher mean of abortion ratio. Also, in increasing level of education so the women with secondary
women with high blood pressure, heavy physical activity, education were at the greatest risk for spontaneous abortion.
and BMI < 18:9 as well as those who were living in rural Many studies concluded that negative consequences of preg-
areas, mean abortion ratio was less than the others (Figure 1). nancies were more evident in women with higher education
[47, 48]; however, a research in the northwest Ethiopia
4. Discussion reached a conflicting result [36]. As women with secondary
education decide to get married at older ages, factors such
Although the total burden related to maternal abortion and as older age at the first marriage as well as first pregnancy—a
miscarriage is less than 0.02% in Iran, the emotional compli- risk factor for spontaneous abortion—can increase the risk
cations of abortion (such as depression) as well as its physical for abortion.
complications may face the families and women with differ- As shown in this study, the odds of abortion increased
ent psychosocial problems. with the increasing SES. After adjusting the variables, it was
In the current research, the lifetime prevalence of sponta- found that pregnant women with higher SES are 1.36 times
neous abortion was about 26% which is variable between 10 more likely to have abortion. In many of the previous studies,
and 31% in different studies [24, 34, 35]. Despite the fact that significant relationship was found between spontaneous
the prevalence of abortion in this study was consistent with abortion and SES [26, 49].
the previous researches, this result cannot be generalized to The prevalence of spontaneous abortion in women with
the whole society. In fact, abortion may occur in the early hypertension was greater than in those without hypertension,
weeks of pregnancy when the mother is not aware of her and only 6.2% of the subjects who experienced spontaneous
pregnancy. In addition, in countries such as Iran in which abortion had high blood pressure. After adjustment for other
the induced abortion is illegal, it is not easy to know about variables, it was found that women with high blood pressure
the exact burden of different types of abortion. In such situa- were at a lower risk for spontaneous abortion. In the study
tion, women hide the exact reason of abortion in order to conducted in Finland, no significant correlation was found
take the advantage of hospital care. between blood pressure and spontaneous abortion [35], and
The findings of this study suggested that age at the first such finding might be due to the fact that hypertensive
marriage and age at the first pregnancy are important risk mothers get better health care which in turn helps to prevent
factors in spontaneous abortion. Accordingly, the risk for abortion.
abortion in women with the first marriage and pregnancy One of the limitations of this study was employing the
at age greater than 26 years old was 57% and 87% more than self-report questionnaires to be completed by the subjects
the other age groups, respectively. This finding was also con- which may cause a problem in identifying spontaneous and
sistent with previous researches [5, 36]. Scientists believe that nonspontaneous abortions. In Iranian culture and in area
marriage and pregnancy of a mother at older ages increase where people are still stick to the traditions such as where
the risk of abortion, fetal and chromosomal problems, and Kurdish people are living, families and women feel ashamed
pregnancy-related complications [37]. Therefore, as it has for any type of abortion. In addition, the induced abortion is
been recommended, it is necessary to have regular check- illegal if there is no medical justification approved by forensic
ups and tests on the natural development of fetuses in preg- medicine and specialist. Such regulation contributes to not
nant women of older ages. having an exact view regarding the true prevalence and the
According to the findings of this research, secondhand types of abortion. However, in the RaNCD cohort study,
smoking increased the risk for spontaneous abortion but the investigator in line with the protocol of the PERSIAN
not significantly. However, in similar studies, there was a sig- cohort used a local and female interviewer for women, in
nificant relationship between increased abortion risk and sec- order to get the correct answers to the questions. Such inter-
ondhand smoking [23, 38]. There is no single stage at which viewer reassured the participants regarding the confidential-
smoking is safe; thus, pregnant women should keep them- ity of provided answers.
selves away from exposure to tobacco contamination.
Contraceptive pills, as a preventive factor, decreased the 5. Conclusion
abortion risk by 78% which was consistent with the findings
of similar studies [39–41]. It may be because the contracep- For countries such as Iran in which the psychosocial compli-
tive pills also have therapeutic effects, in addition to the con- cation of abortion might be prominent, it is of great impor-
traceptive effect, and they are sometimes used to prevent tance to know its risk factors within a population-based
ovarian cysts or to strengthen the follicles [42, 43]. There is study. According to our results, as the number of pregnan-
also another therapeutic way to reduce abortion risk: the cies, age at the first marriage, age at the first pregnancy, and
use of progesterone hormones prescribed by a gynecologist. education level increase, the risk for spontaneous abortion
Therefore, some hormonal contraceptive methods that con- also increases. While in line with socioeconomical develop-
tain progesterone may play a role in preventing spontaneous ment of women in Iran, all of such factors are increasing over
abortion [44]. the recent years, preventing abortion among such women in
In line with the findings of previous studies, the risk for Iran is of great importance. In fact, strategies should be
abortion increased with the increasing number of pregnan- implemented through mass media, counseling, further edu-
cies [8, 45, 46]. cation, and training about abortion and its risk factors to
 7097, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/4871494 by Nat Prov Indonesia, Wiley Online Library on [24/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 Journal of Pregnancy

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